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Business Licenses, Page 2 <br /> • En order to process the new license,the submittal of this application and appropriate fee should be made as soon as possible. <br /> Please fill out this form and return it to: <br /> City of New Brighton <br /> 803Old Hwy 8NW <br /> New Brighton,MN 551 12, <br /> Attention: Joe Hatch,Code Enforcement Officer. •• <br /> Please fill in the information on the back page and return this form along with your application to the agency issuing the <br /> license. Do not return this form to the Department of Revenue. (Please print or type.) <br /> PROOF OF WORKERS'COMPENSATION INSURANCE COVERAGE <br /> Minnesota Statute Section 176.182 requires every state and local licensing agency to withhold the issuance or <br /> renewal of a license or permit to operate a business in Minnesota until the applicant presents acceptable evidence <br /> of compliance with the workers'compensation insurance coverage requirement of Section 176.181. Subd.2.the <br /> information required is:the name of the insurance company,the policy number,and dates of coverage or the <br /> permit to self-insure. This information will be collected by the licensing agency and put in their company file. It <br /> will be furnished,upon request,to the Department of Labor and Industry to check for compliance with Minnesota <br /> Statute Sec. 176.181,.Subd.2. <br /> • <br /> This information is required by law,and licenses and permits to operate a business may not be issued or renewed <br /> if it is not provided and/or is falsely reported. Furthermore, if this information is not provided and/or falsely <br /> reported, it may result in a$1,000 penalty assessed against the applicant by the Commissioner of the Department <br /> of Labor and Industry payable to the Special Compensation Fund. <br /> Provide the information specified above in the spaces provided,or certify the precise reason your business is <br /> excluded from compliance with the insurance coverage requirement for workers'compensation. <br /> • Insurance Company Name: <br /> (NOT the insurance agent) <br /> Policy Number or Self-Insurance Permit Number; <br /> • <br /> Dates of Coverage: <br /> Or <br /> [am not required to have workers'compensation liability coverage because: <br /> I have no employees covered by the law. <br /> Other(Specify) <br /> I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH REGARD TO BUSINESS <br /> LICENSES,PERMITS,AND WORKERS'COMPENSATION COVERAGE,AND[CERTIFY THAT THE <br /> INFORMATION PROVIDED IS TRUE AND CORRECT. <br /> (Signature) <br /> 40 FAILURE TO FILL THIS APPLICATION OUT COMPLETELY WILL DELAY YOUR LICENSE <br />